Zuri Barniv

Apr 212017
 

 

Short Answer: Probably not. Tooth sensitivity can be caused by many things besides cavities. Cavities need to be really deep to cause any symptoms at all.

Long Answer: In my office, when a patient comes in to see me with a complaint, about 9 out of 10 times that complaint is, “my teeth are sensitive”. In many cases, their assumption is that they have a cavity. It’s important to know that about 90% of the time, those sensitive teeth have nothing to do with cavities at all. The culprit is usually something that has sensitized teeth to biting pressure, cold, hot drinks or sweets. Below are the most common causes of tooth sensitivity (besides cavities) and some things to try to troubleshoot the problem.

Typical causes (besides cavities):

1. Sinus infection – Above your top back teeth is an air space which connects to your nose. That air space is called a sinus and it can fill up with fluids, especially when you have a cold or allergies. When this happens, it can directly impact the sensation felt by your teeth and you might describe it as an “ache” which is hard to pinpoint as coming from one specific tooth. Symptoms that would indicate your sinus is the likely culprit for your tooth sensitivity include pain that changes as your head position changes (if you tilt your head to the side, does it hurt more or less?), pain during a time you have a sinus infection, allergies or just a cold/flu.

2. Wear (on the tops or sides of your teeth) – You may be grinding your teeth at night and are unaware of it. Before you confidently profess, “I don’t grind my teeth!”, I would ask how you know that? You are not aware of nearly anything you do when asleep, and grinding your teeth during the night is extremely common. That grinding wears away protective enamel that keeps your teeth from being sensitive much like you might strip a house of its insulation.

Similar to wear on the tops of your teeth, you can also have excessive wear along the sides of your teeth as well. This can occur when you brush your teeth too hard or with a brush that isn’t soft. You would be surprised how much tooth you can wear away even with a soft brush. Need convincing? Remember that the Grand Canyon was formed by just water! If you use “whitening” toothpaste, the problem gets compounded because whitening toothpaste doesn’t actually whiten your teeth chemically, it simply removes stains more aggressively by using rough sandpaper-like material in the toothpaste. This makes them appear whiter, but that sandpaper-like material also strips away more insulation around your teeth.

If the biting surfaces of your teeth have too much wear, you might even feel a little “zap” on one tooth when you bite on it with a specific piece of food. Your next bite may have no pain at all and then five bites later…”zap!”. This is usually caused by a food particle pressing on just the right spot where you have excessive wear and where the tooth is more sensitive.

3. Foods and Acids – There are many foods/drinks that sensitize teeth because they are rather acidic. Acids actually strip away a microscopic film of protection around teeth that makes them more sensitive (examples: soda water, lemon juice, apples, pineapple, citrus, tomatoes, sauerkraut, etc.). If the acids are particularly strong, they can literally melt small craters on the tops and sides of your teeth and we call that “erosion”. This can sometimes occur if you have GERD (heartburn) as the acids from your stomach literally come back up into you mouth (usually at night) and then sit on your teeth. There are other causes of erosion, but untreated heart burn is a common cause.

4. Tooth Grinding– We already discussed how tooth grinding can wear away your tooth and cause problems, but in this case I am referring to pain caused by the actual pressure of your teeth clenching and grinding together for hours at a time at night. Again, you are not likely to be aware of this problem just as you are generally unaware if you snore or talk in your sleep. If you do grind your teeth, that pressure can cause the nerves around your teeth to get sensitized and hurt during the day. Imagine you are a couch potato and I somehow convince you to run a half marathon in the morning. The next day your muscles will be very sore and even if you just walk to the kitchen, you will feel pain with every step. The same thing can happen with teeth.

5. Referred Pain – Sometimes we feel pain in our teeth even when the source of the problem is not actually our teeth. Pain from a sinus problem is one example we already discussed. There are many other causes like an issue with your jaw joint (TMD), teeth that are erupting like adult teeth in children or even wisdom teeth in adults, a cold sore, gum infections and even some diseases can create a situation where you feel pain in your teeth when the teeth are perfectly fine.

CLICK THE IMAGE FOR A SUMMARY OF SYMPTOMS AND SOLUTIONS

 

Signs you might have a cavity:

  1. Severe pain – Usually the sensitivity caused by the five causes above is not severe. On a scale of 1 to 10, most people would describe the pain as a 2 or 3 out of 10 and sometimes as high as five. Pain caused by a cavity typically feels much worse like a 9 or 10 on that scale. Tooth pain might keep you from sleeping at night.
  2. Constant and lingering pain – Tooth pain generally does NOT start when you drink something cold and then disappear. A tooth problem will hurt and continue to hurt for a long time, perhaps for days or longer. If you feel pain when you drink something cold and the pain disappears immediately after you swallow, it is unlikely to be caused by a cavity and more likely from one of the causes in the list above.
  3. Spontaneous pain – A problem caused by a cavity usually isn’t triggered by cold or sweets. The pain usually happens spontaneously.
  4. Swelling – If you see swelling around a particular tooth, a bubble that “pops” right next to a tooth or see pus coming from specific area, this is more likely to be related to a specific tooth problem.
  5. Focused pain – If you feel an “ache all over”, something else is likely going on besides a cavity. Pain caused by cavities typically cause one specific tooth to hurt, not a group of them. If you can tap on just one tooth and feel a problem, then that is more likely a cavity or tooth-related issue.

You might have one of these issues above and it does not necessary mean you have a deep cavity. There may be other explanations, but when I see patients that do have a deep cavity, they usually present with one or more of the symptoms listed above.

CONCLUSION:

Hopefully I have made it clear that when you have sensitive teeth, there are usually many good explanations besides a cavity. The most effective advice I give to patients when I have ruled out cavities as a cause of their sensitivity is:

  1. Discontinue use of any whitening products (rinses, toothpastes, bleach gels, etc).
  2. Buy sensitivity toothpaste (ANY toothpaste that has 5% Potassium Nitrate). No need to buy any specific brands, they are all identical.
  3. Brush gently with the softest toothbrush you can find or use a good quality electric toothbrush, which I think is better than a manual brush anyways.

Remember that if you feel pain when you drink something cold and the pain disappears immediately after you swallow, it is unlikely to be caused by a cavity.

Lastly, if in doubt, see your dentist for peace of mind and confirmation.

Please leave a comment if you have further questions or feedback.

Jan 302017
 

Short Answer: It is mostly safe in very small quantities and you should use it, but only in topical form (not swallowed). Say NO to fluoridated drinking water.

Long Answer: I don’t think I could take on a more contentious dental question than this one. There are two opposing views on this subject ranging from “fluoride is poison” to “fluoride is one of the greatest public health achievements in the 20th century (Source: cdc.gov).”. Both sides are extremely passionate about their point of view.

SUMMARY

The American Dental Association (ADA) has been a vocal proponent of fluoridating drinking water for over 40 years and today, over 70% of the U.S. population is served by fluoridated water. [source].  The ADA is certain that fluoride supplied by drinking water and toothpaste lowers the chance of developing tooth decay and that it is perfectly safe.

Opponents simply feel that fluoride is a poison, even at very low concentrations.  They equate fluoride to lead, arsenic and other harmful materials.  They attribute the use of fluoride with things ranging from Alzheimer’s disease and Attention Deficit Disorder to irritable bowel syndrome, joint pain and cancer.

The trouble lies in the fact that non-biased information is hard to come by, and most sources are either strongly for or strongly against fluoride. I have some mixed feelings on the topic myself, and it would be disingenuous to claim I have the right answer – but I do think I have a reasonable, middle-of-the-road answer.

There is no debating the fact that fluoride is poison, but it’s equally important to put that statement into perspective:  Everything is potentially poison at a high enough dose and fluoride is no exception.  Take Vitamin D for example, which has been credited with strengthening bones, reducing the risk of certain cancers and many other important beneficial purposes.  It is so widely supported, that most store-bought milk and breakfast cereals are fortified with it.  Yet, at too high a dose, Vitamin D can cause your heart to beat irregularly, damages your kidneys and even increases your risk of cancer [source]. At a high enough dose, Vitamin D will kill you.  But then again, just about anything at a high enough dose, including plain water, will kill you too.  So the point is this: like Vitamin D, fluoride is toxic at the right dose.  The difference in opinion often comes from what constitutes a “toxic” dose.  While the ADA feels that 0.7-1.2 parts per million in drinking water is perfectly fine, holistic sources feel that no amount is safe.  So who is right?

DISCUSSION OF FACTS

Let’s start by discussing the supposed advantage of fluoride:  When minerals like calcium and phosphate leech out of your teeth in acidic conditions, the resulting softness is known as a cavity (caries).  Acidic conditions are usually caused by a specific strain of bacteria that digests sugar in your mouth and converts it into acid. But studies show that when fluoride is present, it helps tooth structure take back some of that lost calcium and phosphate. It actually forms a new material called fluoroapatite.  Unlike the original calcium and phosphate ions, fluoroapatite leeches out of the tooth in significantly more acidic conditions (pH 4.5) than just calcium and phosphate do normally.  In fact, it takes an environment that is about TEN TIMES more acidic to cause fluoroapatite to leech out than just normal calcium and phosphate ions. Bottom line: It takes a lot more acid for a cavity to form, thus, fluoride makes the tooth resistant to cavities.

It is hard to debate the science behind fluoride and the beneficial effects it has on a tooth’s resistance to tooth decay.  At the same time, the potential toxicity it possesses cannot be dismissed.

ASSUMPTIONS

Before drawing conclusions, it’s important to make some assumptions:

  1. Let’s assume that fluoride is potentially toxic even at low concentrations. This is because you cannot scientifically prove that fluoride is completely safe at any dose.
  2. Since I have found little to no scientific evidence supporting the idea that fluoride is absorbed readily through the inside of your mouth, let’s also assume any fluoride placed in your mouth that is then rinsed out thoroughly will have a negligible impact on the blood level of fluoride in the body. If you want to argue that an undetectable amount of fluoride does get absorbed, then I address that in point #5.
  3. Let’s assume that the cavity-fighting effect of fluoride occurs when it contacts the teeth directly in the mouth, not when it is secreted by saliva or when it is circulating in the blood. We know this to be true from other scientific articles I agree with.
  4. Let’s assume you believe, as I do, that ridding your life of fluoride would likely increase your chances of getting a cavity. Most studies agree with this point so we will take it at face value.
  5. Lastly, we assume it is impossible to live a completely 100% fluoride-free life, because fluoride is found in almost everything from rain water to tea, vegetables, fruits, meats, milk and eggs. It is everywhere. Do a little research and you will see. Here is a nice start.

One final assumption I have to make is that most people want to keep their teeth healthy and want to have cavities properly fixed.  But doing so involves many chemicals that are equally or more toxic to the body.  It is common to use materials that contain bisphenol A, mercury, strong acid gels and other toxins when repairing tooth decay.  So if one were to get more cavities and need more fillings as a result of using less fluoride, would they not be ironically exposing themselves to different unwanted chemicals over the long-term?  And since fillings often don’t last a lifetime and need replacement and repair, this could be a potentially serious concern for fluoride-free advocates.  On the other hand, some believe chronic low level fluoride exposure could lead to potential health implications. So which is worse?  We have already assumed that no meaningful amount of fluoride is absorbed through the mouth and that the positive effects of fluoride happen locally in the mouth, not systemically when it is swallowed.  So there is no need to ingest it. I believe the bulk of the problem is solved when you limit fluoride exposure to just your mouth and for a short time.

CONCLUSION

Perhaps the pro-fluoride crowd is 100% correct and there are absolutely no adverse health implications to chronic low levels of fluoride.  Or, perhaps they are wrong and this won’t be revealed for another two decades?  My logic guides me to not risk it if I can easily help it – and I can.  I have chosen to use reverse osmosis filtration in my house to remove fluoride (among other things) but I do use fluoridated toothpaste. After brushing with it once a day using a pea-sized portion and for two minutes, I thoroughly rinse my mouth out with water.  I continue to rinse until I don’t taste any of the toothpaste flavors.  In this way, I get the benefits of fluoride with minimal risk.

As for municipal water fluoridation, this is a contentious issue.  My world view largely dictates a more libertarian approach, whereby, I prefer to empower people with knowledge and let them make informed decisions.  I am personally not in favor of forcing anyone to ingest anything in the name of public health.

Perhaps fluoride is indeed one of the “greatest public health achievements of the 20th century”, but my personal issue with water fluoridation is that one has to actively take measures to remove it if they disagree. Adding iodine to salt has been a very important step in reducing iodine deficiency, something that leads to a host of terrible and preventable health problems.  Nevertheless, when I go to the grocery store, I can still choose between iodized and non-iodized salt.  When I drink from a public water fountain, I do not get that choice.

The pro-fluoride movement also feels strongly that they are helping the “under-served” and “poor” who cannot afford the best dental care or aren’t as empowered with knowledge that prevents tooth decay. I personally find that a bit simplistic and borderline patronizing. Just because someone is poor doesn’t mean they are not intelligent enough to make an informed decision. But if they are poor then they are much less likely to afford a filtration system which rids their tap water of fluoride. In other words, the poorest in our population are being forcibly medicated while the well-off can opt out more easily.

FINAL POINTS

♦ I think fluoride that only touches your teeth and the insides of your mouth is probably safe. Doing so will decrease your risk of getting cavities, which is good.

♦ I recommend brushing your teeth with a very small amount of fluoridated toothpaste at least once a day and rinsing it out completely afterwards.

♦ Do not expect to live a 100% fluoride-free life. You are living in a dream world if you do.

♦ I strongly disagree with medicating the population by fluoridating tap water and also causing the masses to actually ingest this medication (fluoride is only useful when it touches the teeth). I find it disingenuous to use the argument that the poor don’t know enough to make their own decision.

♦ Filter out fluoride from your water if you can and don’t ingest fluoride if you can help it.

Care to comment? Concerns? Questions? Give me your thoughts below.

Jan 142017
 

Short Answer: Sometimes they do, but usually they don’t.

Long Answer: When you go to a dentist in the USA, you may see many things in front of or after their name. There are differences, but for general dentists, the differences don’t add up to very much. We will assume that we are only talking about dentists who are legally licensed to practice and not some horror show dentist that pretends to be one even though they are not:

Man Arrested for Practicing Dentistry Without a License Pulled 10 Teeth Without Anesthesia in His Fake Office

Unfortunately, there are many examples of things like this. But if they are legitimate, here are some of the things you will see and what they mean to you:

Dr. Bob Smith = All dentists are doctors, you may see them addressed this way by their staff and peers. It doesn’t really indicate anything other than that they achieved a doctoral degree somewhere at some time. My dad has a PhD degree (a doctor of philosophy degree) in engineering. He is not a medical doctor by any stretch, but on his letterhead, he lists his name as Dr. Barniv just like me! People who are unlicensed medical doctors that received their degree in another country could still refer to themselves as “Dr. Smith”. The designation doesn’t really tell you anything.

Bob Smith, D.D.S. = This is a ‘doctor of dental surgery’ and most dentists that obtained their degree on the West Coast have a DDS degree. There are differences, in my opinion, between west coast and east coast dental schools and their corresponding education, but we will leave that to another discussion.

Bob Smith, D.M.D. = This is a ‘doctor of medical dentistry’ and most dentists that obtained their degree on the East Coast have a DMD degree. There is no difference between a DDS and DMD in the eyes of the law. There is essentially no difference between the two degrees for you, the patient.

Bob Smith, D.D.S., FAGD = A dentist with a DDS degree who went on to become a ‘fellow in the Academy of General Dentistry’. This means he pursued extra education in various topics and the AGD (Academy of General Dentistry) recognizes him as achieving a certain level of knowledge. Usually a required amount of continuing education is completed and then tests are administered. A dentist with a FAGD is usually someone who puts priority on their level of education, but it does not necessarily mean they are a better dentist or have special skills. You may also see MAGD at the end of their name which is one step further up the AGD ladder.

You may see many different letters after the DDS besides FAGD which means they are a fellow of some other organization (i.e. they did a lot of studying and took tests in that particular area of dentistry). The designations almost always start with ‘F‘. For example FAACD = Fellow of the American Academy of Cosmetic Dentistry. FAAID = Fellow of the Academy of Implant Dentistry. These designations certainly show that dentist’s dedication to that particular field of study. They are not considered specialists in that field, but you can bet they probably know more about it than the average dentist.

Bob Smith, D.D.S., PC = The ‘PC’ at the end doesn’t mean they are politically correct dentists 🙂 . It means they have registered their name as a “professional corporation”. It is essentially meaningless to you, the patient. If a dental office is listed as an ‘LLC (limited liability corporation)’, ‘Inc. (incorporated)’ or similar, it is also pretty meaningless. It is just another way to list a practice. Most practices limit their liability this way and it has essentially no effect on you.

Bob Smith, D.D.S., MSD = This means they are dentists that have received a ‘Masters of Science in Dentistry’. This dentist has pursued more education at an accredited university and it typically goes along with dentists who are also specialists like orthodontists. You may also see an MS degree which is a ‘Masters of Science’.

Bob Smith, D.D.S., MD = This is a dentist that also has a ‘Medical Doctor’ degree. That is the same degree your family physician has and it is usually awarded to dentists that completed training in oral surgery (oral surgeons).

Unfortunately for you, this list is not exhaustive. There are so many different designations for dentists that even I don’t know what they all mean. The internet is your friend. If in doubt, look it up. Sometimes the letters mean something and sometimes they don’t. I have seen dentists try to make themselves look better by adding more letters that really don’t mean much. For example, you need a bachelor’s degree (BS or BA) in order to get into dental school in the USA. This means you did 4 years of college. A dentist with a DDS degree is assumed to have a BA or BS. But some dentists will write their name Bob Smith, B.S., D.D.S. to make themselves look smarter than they are. I would be weary of someone who writes their name this way. If they wrote their name as Dr. Bob Smith, B.S., D.D.S., then they might have some kind of inferiority complex…

So as always, be alert and look it up if you aren’t sure!

May 172016
 

Short Answer: Yes, but it requires some homework.

Long Answer: This question recently came up and I thought it was an important topic. Many times when my patients leave the area and need to find a new dentist, they ask me for tips on finding an “honest” one. Dentistry is one of those industries that can harbor unscrupulous practitioners and doesn’t always have the best reputation in that regard. I believe that stems from the fact that most dentists practice alone or with a partner in a small clinic setting with little or no oversight.

Imagine if you went to work every day and your boss had no idea what you were doing. All they knew was whether you were sitting at your desk doing work or not, and they were checking to see you weren’t causing harm to the company. You were generally paid well whether you did a good job or not. Now also imagine telling your boss you had more work to do today than you did yesterday, even though you basically made up most of that “new” work. Not only would you still get away with doing a crummy job, but your boss would also give you a raise for supposedly doing more!

This is the situation most small clinic private dental offices find themselves in. The patient only knows if it hurts or not, if it costs a lot or not and if it looks good or not. Beyond that, there are few metrics the typical patient can measure against. But what about all the stuff behind the curtain? Were good materials and labs used? Will the work hold up like it’s supposed to? Were possibly better and less expensive options presented? Was any work needed in the first place? That’s where ethics come into play. So here are some tips on finding an honest and ethical dentist. Feel free to add comments if you have your own ideas or tips. Keep in mind this discussion is most relevant to USA-based doctors and patients. I am not well-versed with international dental practices (with few exceptions).

DENTISTS TO AVOID

  1. Avoid Over-Marketed Dentists – If you have been seeing ads all over town for a dental office, be careful. This may be a sign of a “hungry dentist” (see next point). An office that advertises heavily has spent a lot of money on marketing and possibly less on patient retention and patient satisfaction. I had to market myself when I first opened my practice, but I did it for a limited time and it had limited scope. Once people started coming, I developed a reputation and word-of-mouth took hold. If I was not doing a good job, then I would have had to keep marketing to get a steady flow of patients in the door. This is why your Spidey-senses should be tingling if you see an ongoing heavy marketing presence for a particular office. Also, advertising is very expensive and it takes a lot to make back that investment. When ads get someone to call for an appointment, there is extra pressure to make sure that new patient generates a worthwhile profit. Finally, be weary of big “one-time” promotions, coupons and special deals just to get you in the door.
  2. Avoid Hungry Dentists – Hungry dentists are those that desperately need to generate more work in order to keep their practice afloat, so they are also highly motivated to recommend excessive treatment. There are dentists that are generally “hungrier”, like new graduates with very high debt, dentists having financial problems, dentists that are seeing a steady decline in new patients, etc..  Not to say all the latter are dishonest, but a desperate dentist is not your friend and it’s not always possible to explain how to spot one. One way is if a dentist recommends treatment and then exerts a great deal of pressure on you to commit and proceed with treatment immediately. There are other ways, but suffice it to say that most people can spot a hungry lion a mile away. This is no different and I would stay away from both. When in doubt, trust your instincts.
  3. Avoid Offices That “waive your deductible and co-pay” – If you have insurance, you probably have a deductible or co-payment (co-pay) for certain dental procedures. Some dental offices know that if they waive this co-pay, you will be less likely to resist their questionable recommendations for treatment. Hey, if it doesn’t cost you anything, who cares, right? Wrong! Just because a procedure is free doesn’t mean you need it, want it or it won’t cause you more pain and problems later. But even if you are convinced you need the treatment, the dentist usually has a contract with your insurance company which dictates the maximum fee they can charge and your required co-pay. The insurance dictates a co-pay is required because they know they will pay for fewer procedures if a patient has to pay for some of it. That calculation ultimately affects your insurance premiums. So when a dentist waives the co-pay, he is inadvertently making the delivery of care more expensive for everyone AND he is also potentially violating his contract with the insurance company. Bottom line: do you think a dentist that is unethical when dealing with the insurance company is suddenly going to be ethical when dealing with you? You know the old saying: “Once a cheater, always a cheater.”.
  4. Avoid Office’s That Get New Patients Through the Insurance Company – If you have insurance, they will send you a list of dentists you should go to. They really, REALLY want you to go to one of them. That’s because they have a contract with the dentists on that list which dictates how much the dentist can charge and other terms and conditions, most of which they control. Dentists that rely on the insurance company to refer patients to them often have not invested their time and energy in making their practice driven by referrals from other patients. They don’t really need all their patients to be so happy because the insurance keeps sending them new ones. Also, the insurance typically pays these dentists much lower fees for procedures that are covered. The dentist is required to accept these lower fees in exchange for all those new patients the insurance company sends them. So to get around accepting those very low fees, the dentist may recommend you do more expensive treatment that is normally not covered by your insurance (see next point below). Bottom line: find a dentist on your own, not necessarily through the insurance.
  5. Watch Out For Up-Selling – This was touched on above. Dentists that are “In-Network” for many insurance companies make the lion-share of their income by “up-selling” treatment. For example, you haven’t had a cleaning in a while but there are no underlying gum issues. A shady dentist will tell you a “deep cleaning” is required even though a basic cleaning would have been perfectly fine (CLICK HERE for a thorough explanation about this). You need a crown on a tooth but the dentist tells you that it costs extra if you want it to be metal-free or made from special materials not normally covered by your insurance. You have a small stain on the biting surfaces of some of your back teeth and the dentist tells you fillings are required there even though the area could be easily monitored for the time being. These are examples of up-selling. If you plan to meet a potential new dentist before your first real appointment (see item #3 below), then consider asking about their style. Ask, “If I have a really, really tiny cavity on the biting surface of my back tooth, would you be comfortable watching that to see if it develops or do you think that needs treatment right away?”. Ask, “If I need a crown, will it be white or do I have to pay more for that?”. Ask, “If I haven”t been in for a while, do you generally think it is better to do a deep cleaning or try doing a simple cleaning first? (you are asking this before they have even looked in your mouth)”. There is no one right answer to these, but the answers you do get should give you great insight into how the dentist and the practice operate. Did the dentist answer thoughtfully and give you a reasonable answer? An honest dentist should be easy to distinguish from a dishonest one.
  6. Be Cautious About High-Technology – Technology is great, but if a dentist advertises that they use lasers, crown-in-a-day machines, special cavity-detection lights, etc., it doesn’t mean they are a fraud. But that technology costs a lot of money and the salespeople they bought it from helped them calculate how many times a month they need to use that machine to make back their investment. Fun Fact: Did you know that a crown-in-a-day machine costs upwards of $165,000? When an expensive machine is sitting there, it is just begging to be used. But not every situation calls for the use of such a machine in the first place. The reality is that an office that has a lot of these expensive gizmos is more tempted to use them even when inappropriate or unnecessary because they are trying to justify their investment. That’s when some of the dishonesty can creep in. And by the way, a lot of the new technology is useful and wonderful, but you don’t need most of it to receive extremely high-quality world-class dental care. Bottom line: Do NOT avoid office’s that use a lot of technology, but DO be more alert about the potential downside to all that technology. If technology and gadgetry is the focus and main selling point of an office, I would look elsewhere. 

DENTISTS TO SEEK OUT

  1. DO Look Up Dentists Online – Yelp.com is not perfect at all, but it is a starting point. You might not find a great dentist necessarily, but you will likely avoid a really dishonest one. Look up a potential name at the Better Business Bureau. You can also look up any dental license at the State Dental Board. In California, the site is found (HERE), but you can look up your own state board and search for actions against the dentist’s license.
  2. DO Find a Dentist With His Or Her “Name On the Door”  This means you aren’t going to a corporate or franchise office where you might see a different dentist every time you visit. Also, typical corporate or franchise offices are quota-based, which means they are hungry lions right from the moment you get in the chair (refer back to the points at the top of the page). When a dentist has their “name on the door” it means their reputation is on the line, not the faceless corporations’. Dentists work hard, spend a lot of time and money to open up their own practice. They are less likely to engage in shady behavior if their personal reputation, and thus their livelihood, is at stake. There is also a far smaller risk of dishonesty when a dentist is free from quotas.
  3. DO Make a Short Consultation Appointment – When you have narrowed your list of potential dentists down to 2 or 3, ask to make a short 5 minute appointment to meet them. This is an opportunity to see what kind of style the potential office has and the appointment should be completely free. You shouldn’t have to tell them more than your name because you are just a “potential patient” and would like to “meet the doctor” to see if it s a “good match”. If they are a reputable and honest business, they should have no problem accommodating this request. When you meet the dentist, you can tell him or her about your fears, concerns and expectations but also hear about their practice philosophy. Consider asking the questions mentioned in the first section (#5 Watch Out For Up-Selling). Your gut will usually tell you who is naughty and who is nice!
  4. DO Get a Second Opinion – When you have found someone and that dentist recommends treatment, consider getting a second opinion just to see if the new dentist is in the ballpark. This builds trust for a long-term relationship. Again, a good and honest dentist should have absolutely no problem with providing you with a written treatment plan, x-rays and his blessings to confirm his diagnosis. If a dentist becomes offended or aggressive about getting more opinions, that is a red flag. The only warning I give about second opinions, and it’s very important to remember, is that dentists recommending the LEAST treatment seem to be the most honest. That is NOT necessarily true. Choosing one dentist over another according to who recommends the least is not in your best interest. Regrettably, some dentists giving a second opinion hope you will switch to their practice, so they low-ball the amount of work they think you need in the hopes this will convince you to see them instead. This is the one caveat to a second opinion. I know…confusing!  So I think the real goal of a second opinion is not to see if another dentist comes up with the same treatment plan, but to see if the first dentist was in the ballpark, if their recommendations were reasonable and if there was anything unusually aggressive that stands out. Incidentally, the best place to get a second opinion is a dental school. Unfortunately, it tends to be a long process and generally too time consuming for the purpose of getting another opinion. Also, many people are geographically too far from a dental school; however, if you are faced with a complex and difficult plan by your dentist and you have doubts, it is exceedingly unlikely you will be bamboozled by a dental school.

EXPECTATIONS FROM AN HONEST DENTIST

  1. Treatment Options – An honest dentist should tell you about all your treatment options (including the option to do nothing). If you have a problem and the dentist only talks about one treatment option or completely dismisses other options, this should be a red flag. Also, you should expect the dentist to explain the options to you, not an assistant or financial coordinator. 
  2. Risks Associated With Treatment and No Treatment – Every procedure has risk. If a dentist recommends doing work, especially expensive elective work, and doesn’t take the time to talk about some of the bad things that could happen, then this is a red flag. There is also risk associated with not doing any treatment, and this needs to be explained as well.
  3. No Bait and Switch – Any treatment that is recommended for you should be given in writing. It should be very clear what the total cost of the treatment will be, with and without insurance. And if there is any question about what other additional treatment could be needed (like a root canal), that should be discussed in advance as well. An honest dentist will not try to sell you on less expensive treatment and then switch to a more expensive one after the work is started.
  4. More Opinions – Again, an honest dentist will have no problem with you getting another opinion at any time.

Is the list above exhaustive? Absolutely not. There is no perfect formula for finding a good and honest dentist, but this is a start and I hope it helps you. If you have more suggestions or comments, please share below and I will update this post as new ideas surface.

Nov 092015
 

Short Answer: In my humble opinion, no.

Long Answer: Yes, it’s true: dental work in the Unites States is expensive. There are good reasons for this and it’s not necessarily greedy dentists overcharging for what they do. It starts with the fact that cost-of-living in countries like the USA are much higher than in places like Costa Rica, Hungary, Mexico, etc.. In the USA, the cost of labor, insurance, real estate, taxes, etc is far higher than in any foreign country we are comparing to in this discussion. It also relates to the longer and more rigorous dental education USA-based dentists have to go through compared to most every other country (including advanced European ones) and the costs associated with that longer education. In almost every developed country, a dental education is 5 years after graduating high school, while in the USA, it is 8+ years. That’s a big difference, especially when considering a US-dental education costs about $60,000/yr in tuition! Costs are also higher due to materials used in the US requiring FDA approved and dental offices having to adhere to much more strict regulations and procedures than in more “lax” countries.

I see questions about foreign dental work come up when people need especially expensive treatment like dental implants, removal of many teeth, dentures or even a full mouth of crowns and bridges. The most expensive treatment a dentist in the United States can charge for is about $60,000, which is a ghastly sum for the majority of middle class Americans to afford. Mind you, $60,000 is for the most extreme and complex cases, while most larger cases fall more into the $15,000 range. Most insurance companies do not even scratch the surface on costs like that. But in a country like Mexico (a short flight for many Americans), any USA treatment costs about ONE THIRD. So a $15,000 USA treatment costs about $5,000 in Mexico. Most of these foreign clinics cater to “dental tourists”, speak English and take care of many travel arrangements to make it easier. But it’s not all roses.

Not to say that some of these foreign clinics do not have well-trained, experienced and talented dentists. The real problem lies with challenges involving follow up for complications and accountability if things “go bad”. There is also much less governmental oversight and the ability to accurately assess the quality of care you are receiving. I have many example of cases where this came up, but here is one:

My patient “John” had many dental problems and he required work totaling over $18,000. The work included 3 implants, 2 crowns and 2 root canals. He told me he could probably afford it all if he had to, but there was no way he would do that when it costs $6,000 in Mexico. So off he went and he came back quite happy. I saw him about 6 months later for a routine examination and took some x-rays. What I noted was that 2 out of the 3 implants had a condition called “peri-implantitis” which means they were failing. The root canals and crowns he had done seemed to be working fine, but they were not done to the standard mandated by the California Dental Board and I surmised they would ultimately need to be repaired as well. When I explained what I saw, it put John in a very difficult position. He had, indeed, gotten a lot done for a lot less somewhere else. But now there were problems and it was not practical for him to fly back to Mexico to have the problems evaluated and corrected in a timely manner. John had to be at work on Monday morning, he couldn’t just leave to Mexico for every follow up procedure and post-operative check that would be required to correct the issues he had. John ultimately required 2 moderately extensive surgeries to correct the problems and it ended up costing him close to $15,000 just to correct the issues with the two failing implants alone. In the end, he spent a total of $21,000 to get what he would have received in the USA for $18,000. That didn’t include the pain and suffering he endured while on “vacation” and when he got back home, the cost of traveling to Mexico and the time he had to take off work to deal with the corrective actions needed. It also didn’t include the repair of the substandard crowns and root canals he had done. John was understandably upset after all this happened. In fact, he even talked to me about suing the dental office that did the work for him, but alas, that was not possible. The laws in Mexico are not like in the USA, and it is far more difficult to sue a dentist in Mexico when you live thousands of miles away. Your potential award will also be significantly less than it would be in the USA, if you prevail at all.

The moral of the above story is not that all foreign dental work will end badly and require expensive corrections. I have no way to know what percentage of these cases fail or are done poorly. What I do know is that corrections are difficult and expensive. The more complicated the dental work, the more likely there will be problems (this is true anywhere including the USA). And what’s more, it is unlikely any of the implants placed in John’s mouth were FDA approved (as is mandated in the USA). It is exceedingly unlikely any official from OSHA inspected the clinic John was treated at to guarantee proper sterilization procedures were utilized. It is also not probable all of the clinic’s employees were licensed and certified to assist John’s dentists during the procedures he received. For that matter, it is not likely John’s dentists had to meet even a fraction of the ongoing requirements USA dentists have to adhere to in order to be licensed to practice.

Bottom line: It is not my opinion that patients should avoid all foreign clinics for dental work outright. However, if and when complications with treatment arise, patients tend to drastically underestimate the time, energy and money required to take care of any such complications back in the USA. It also becomes very frustrating for patients experiencing complications (sometimes due to gross negligence) to find out they essentially have no legal recourse at their disposal. What’s important is that one understands these trade-offs when receiving lower cost but complex dental care in a foreign country before committing to it.

Aug 242015
 

Short Answer: It means the root of your tooth is getting shorter, most likely because of your braces. There is no treatment, but further damage might be preventable.

Long Answer: Hold a pen vertically and stick it in jello. Now move it through the jello while keeping it perfectly vertical. That was easy, right? Now do the same exact thing, but this time put the pen in thick molasses. That took a lot more time and a lot more force to do, right? Also, you might notice that it took even more effort to keep the pen perfectly vertical as you passed it through he viscous material. Now imagine that the pen is a tooth and the thick molasses is the jaw bone. Braces apply forces to the top part of the tooth and it takes a lot of pressure to slowly move teeth through bone AND to also keep them vertically upright. If that pressure is excessive or applied for long periods of time, eventually your body will melt away the end of the root. In other words, your body knows that it’s easier to move a shorter pen through the bone than a longer one…so it makes it shorter. As your root gets shorter, this is known as external root resorption.

Resorption

CAUSES:

There are many factors involved in root resorption, but it seems to happen much more frequently in people that have braces for a long time (many years) and in cases where a lot of force is applied to the teeth (the amount of force can be tuned by the dentist). Also, some specific movements of teeth cause the problem to occur more than others (for example, pushing teeth deeper into bone causes the problem more than pulling teeth out to look taller). Specific teeth seem to be more prone to the problem than others, and the most commonly affected teeth are the front incisors. There are also genetic factors involved, which means one person gets severe root resorption and someone else getting identical treatment gets none. Even seemingly unrelated factors like alcoholism, asthma and allergies can predispose someone to more root resorption. The bottom line is if the roots get short enough, they may start to wiggle when you bite on them or when you press on them with your fingers. In more severe cases, the teeth can hurt. In a worst-case scenario, a severely affected tooth might need to be removed (but this is quite rare). It is important to note that even in mild cases, any amount of resorption does make the tooth more susceptible to problems over a lifetime than if it was never affected with this problem. This is why I repeat what I have stated in other blog posts: there is no such thing as a risk-free dental procedure and you should always insist on being fully informed about the risks, benefits and alternatives of the treatment you are undertaking.

PREVENTION / TREATMENT:

The easiest prevention is to avoid braces, which may not be an option for some. If you have chosen to get braces, it is recommended the dentist take x-rays periodically and throughout your treatment to make sure resorption is not occurring. If it is, your treatment can be ‘paused’ sometimes for several months, as your bone and teeth have time to recover. Studies show that taking pauses in treatment and reducing the amount of force applied to the teeth greatly reduces the risk of external root resorption. Some patients object, however, because it can significantly increase the time in braces overall.  If resorption occurs rapidly and persists even after pausing treatment, the treatment may need to be stopped early altogether.

It is important to remember that not everyone who has braces gets external root resorption, but it is a risk. Once resorption occurs, there is no treatment to recover the lost part of the root. This makes the tooth more susceptible to gum disease and other problems over a lifetime. Ultimately, the tooth could be lost at an earlier age – an outcome everyone wants to avoid.

Jul 222015
 

Short Answer: Maybe

Long Answer:

When reading comments online and hearing concerns from patients, issues revolving around deep cleanings are some of the most common. But hold on to your hats, this is going to be a doozy. If you don’t want all the nitty-gritty about deep cleanings, stop now and go back to whatever else you were doing. This subject takes some work to do it justice.

WHY ARE DEEP CLEANINGS RECOMMENDED AT ALL:

Healthy gums are tight, pink and don’t bleed when they are brushed or flossed. A dentist or hygienist can take a little ruler called a periodontal probe and measure the depth of the pocket of gum that forms near the base of your tooth. A measurement of 1-3mm with no bleeding is considered healthy and normal.

Normal tooth

Normal gums and jaw bone. Notice the probe is measuring less than 3mm in pocket depth and the gums appear pink and hug the tooth tightly.

When teeth are surrounded by a constant irritant like food debris or plaque (the soft white film that you can scrape off with your fingernail), the gums swell a little and they tend to bleed easily. Because the gums swell slightly, it makes the pocket of gum seem deeper and it may be 4-5mm in depth. This is called gingivitis and it is reversible. But if the soft white plaque is not properly removed for a few days, it begins to mineralize into a hard cement-like substance called tartar (“calculus”, also known in other countries as “stone”.) Tartar cannot be removed with a regular toothbrush or by flossing.  Over time, tartar builds up under the gums where it can be difficult to see, and this creates a constant irritation to the gums and bone it contacts. Ultimately, the jaw bone holding the teeth tends to “melt” away. This gradual, non-reversible bone loss is called “periodontitis” and this will be reflected in even deeper pocket depth (usually exceeding 5mm). Again, to clarify, if there is no actual loss of bone and only the gums are red and inflamed, the condition is called “gingivitis”.

Although bone loss is a key component to periodontitis, the term is surprisingly not perfectly defined and two dentists can look at the same patient and come to different conclusions. That’s because a dentist uses a combination of periodontal probing measurements, x-rays, clinical observation and their experience to make the diagnosis. If, however, periodontitis is diagnosed, it is common to recommend a deep cleaning as a first step. Subsequent steps may include surgical intervention. If periodontitis continues unabated and untreated, the teeth affected could eventually become loose, painful or fall out. This is because the support structure for the teeth (your jaw bone) is no longer present in sufficient quantities. See the figures below:

Moderate perio

This shows both gingivitis (swelling of the gums) and periodontitis (a more advanced state where bone loss occurs)

Severe perio

This is the most severe form of periodontitis. There is basically no more bone holding the tooth in the jaw and the gums bleed easily when touched. Some people may see pus coming out of the gum pockets when pressed. Teeth in this state tend to move more easily and some people report noticing their teeth have “shifted” from their original position.

In addition to losing teeth, many studies point to evidence that periodontitis can exacerbate or trigger problems throughout the body. There have been links to arthritis, diabetes, heart disease, stroke and more. Obviously that doesn’t mean periodontitis causes these things directly, but it is thought that chronic inflammation in the body can trigger or exacerbate other medical conditions. There is even a link between gum disease (periodontitis) and pregnancy-related problems like pre-term deliveries, miscarriage, low birth weight and other issues. It is important to remember that the surface area of the gums in your mouth is about equivalent to that found on the palm of your hand. Imagine if your palm was red, inflamed and bled when you touched it. One would think that would be reason enough to seek treatment. Clearly, periodontitis is a serious problem with potentially serious consequences.

SO WHAT IS A DEEP CLEANING?

A deep cleaning, also known as scaling and root planning (SRP), is the procedure which removes the deposits (tartar) under the gums which cause the chronic irritation and bone loss. In a SRP procedure, not only are deposits removed from the root surfaces, but those surfaces are then smoothed (planed) so they become more resistant to further buildup. Sans surgical intervention, the bone lost will never regenerate and this is why many authorities consider periodontitis a treatable but incurable disease. Since deep cleanings require the dentist or hygienist to clean under the gums, most people find the experience too painful to do without anesthesia. It is very common to have one half of the mouth cleaned at a time. After two visits, the process is complete. It is then recommended that the patient return every 3 or 4 months for a “maintenance” procedure. This assures the dentist that the tartar is kept from reforming under the gums and evidence that the therapy was effective is gathered. It is not uncommon for dentists to also make a referral to a gum specialist (a periodontist) to further evaluate and treat periodontitis.

WHAT DOES IT ALL MEAN FOR THE YOU?

I agree with the merits of a deep cleaning and I, occasionally, recommend it to my patients. The unfortunate thing is that many practitioners use this service to augment their bottom line and the patient is powerless to know if the recommendation was warranted or not. Remember in the above discussion that the term “periodontitis” is not defined in stone. It is diagnosed by looking at many different things. Some dentists define periodontitis so liberally that nearly all their patients are recommended this procedure. But most dentists use guidelines set by insurance companies to define periodontitis and the need for a deep cleaning. In other words, if the insurance company would agree to pay for the procedure, the dentist is likely to recommend it. Most insurance companies expect pocket depths to be more than 4mm and across several teeth in each quadrant of the mouth before they agree to cover a deep cleaning. Most insurance companies also require a copy of recent x-rays and a written diagnosis to approve the procedure. But even with x-rays, the pocket measurements are somewhat subject to interpretation and to the specific operator. Combined with the fact that there is a large financial interest in doing a deep cleaning over a regular cleaning, the operator may be motivated to use the most liberal of interpretations when probing pockets. This may not be in your best interest. To illustrate these points, we will look at two scenarios:

Scenario #1:

Trevor, who hasn’t been to a dentist for “several years”, comes to the dental office for a “check up and cleaning”. The dentist completes an exam, x-rays, evaluates the pocket depths and the overall health of his gums. Since Trevor hasn’t been seen by a dentist in quite a while, he has some plaque and calculus (tartar) around his teeth and in some areas where it cannot be seen easily, but it is minimal. In looking at the x-rays, the dentist confirms some of what he saw in the exam and confirms the problems are present but localized to a few areas. The dentist completes a full mouth probing and finds that Trevor has a few back teeth with 4mm and even 5mm pockets. The dentist also notices that some areas bleed slightly when he does the probings. The dentist decides to take a more relaxed approach and proceed with a regular cleaning (prophylaxis). He advises Trevor to return in 6 months to recheck the areas and to look for signs of chronic and persistent problems. The dentist receives about $100 when his hygienist does this simple cleaning, it takes an hour to do it and the office will earn another $100 in 6 months when Trevor returns for his second cleaning. Since the hygienist is paid $50 per hour, the office makes a profit (before non-salary expenses) of about $50 for this cleaning.

Scenario #2:

Trevor goes to a different dentist under the same circumstances. In this case, the second dentist makes a different judgment call and recommends a full mouth deep cleaning (four quadrants of SRP). The hygienist completes this service in about three hours which is spread over two appointments and the office collects $1,000 for the procedure. As is customary after a deep cleaning, Trevor is instructed to return in 3 months for a maintenance procedure which costs about $150 (maintenance procedures cost more than regular cleanings and are recommended more frequently). In this scenario, the office took three hours to make a $850 profit in the time they would normally make $150 ($50 x 3 hours) with regular cleanings. Furthermore, Trevor is now expected to return every 3 months for a maintenance procedure which translates to a $100 profit at each appointment (as opposed to $50 for regular cleanings). Since this procedure is recommended much more often than a 6 month cleaning, the office makes a $400 profit the following year as opposed to $100 when only considering the “maintenance” Trevor will need.

THE MONEY-MAKING DEEP CLEANING:

The numbers add up quickly: Over two years, the dentist in the first scenario doing only regular cleanings made $400 using 8 hours of his hygienist’s time ($50/hour profit). The dentist in the second scenario doing a deep cleaning made $1,550 using 10 hours of his hygienist’s time ($155/hour profit). So when a dentist is looking in Trevor’s mouth and deciding on the diagnosis to make, it becomes extremely tempting to choose the path which assures a much greater profit. Most patients would assume that the licensing authority, dental society or even the insurance companies would catch a dentist who over-recommends SRP. Unfortunately, that assumption would be wrong. One reason is that measuring pockets is time-dependent and, as discussed previously, is relatively subjective in nature. For example, a dentist accused of recording pockets deeper than they actually were could say the gums were particularly swollen on the day the readings were done. That would be nearly impossible to disprove. Also, when measuring pockets, the ruler used is typically based on 1mm increments (see the first figure at the top of this post). Dentists are typically taught to round up not down. If a pocket is 3.5mm deep, the dentist will almost always record it as 4mm. That could be the difference between “healthy” and “diseased”. Also, there is quite a lot of difference in how pocket measurements are done. Some practitioners push really hard and others use a very gentle touch. A firm hand will cause the ruler to go further into the gums which will give the impression that the pocket was deeper than was recorded by the gentle operator. Firm probing is also more likely to make the gums bleed, again, reinforcing the diagnosis of periodontitis. Even x-rays can be misleading, giving the illusion that there is no bone loss, when in fact, there is, and vice versa. That is because x-rays look at 3-dimensional objects in 2-dimensions. This is why some insurance companies don’t require x-rays at all and why a dentist can claim a diagnosis of periodontitis without any objective evidence. Unless the situation is overtly fraudulent and the dentist is diagnosing periodontitis for every single patient, it will be nearly impossible to prove any nefarious intentions. Some unscrupulous dentists take advantage of this situation and convince patients they need a deep cleaning when, in fact, it is totally unjustified. I have seen this more times than I wish I had…

A PATIENT’S PERSPECTIVE:

Since a deep cleaning is relatively invasive, it is my opinion that any dentist who recommends it without genuine need is behaving unethically. There is nothing worse than taking advantage of someone’s lack of knowledge for profit and these situations are extremely troublesome.

In my office, if a patient has a few 4mm or 5mm pockets, some bleeding gums and a little bone loss in isolated locations, I don’t rush to recommend a deep cleaning. Typically we start with a simple cleaning and have the patient return in 6 months or less. At that appointment we evaluate the situation again. If the buildup of tartar under the gums is persistent, there is still bleeding and the areas we worked on have not improved, we will have a discussion with the patient about the merits of SRP. We will review the risks, benefits and alternatives before making a decision together. Sometimes we decide to wait another 6 months, sometimes we recommend they see a periodontist (gum specialist) and sometimes we elect to do SRP.

If a new patient comes to my office who hasn’t seen a dentist in a few years, there is calculus under the gums throughout their mouth, many deeper pockets in excess of 5mm, obvious bone loss and bleeding on probing throughout the mouth, we will recommend SRP or refer them to a periodontist. In this case, I believe (remember, this is all dentist-specific) the recommendation is justified. Sometimes patients that clearly need SRP will ask to postpone the procedure and to instead get a simple cleaning. This is usually discouraged. If only the areas above the gums are cleaned (this is what’s done in a simple cleaning) and calculus remains under the gums, this can cause the top part to heal and the deep parts not to. In the worst case, this can lead to a gum infection which can then lead to more serious issues. Ironically, these are cases where it is better to do nothing than to do a simple cleaning (if those were the only options).

There are some important things to keep in mind if a deep cleaning is recommended and a decision to proceed is made. Most patients cannot tolerate the procedure without local anesthesia because the work happens fairly deep under the gums. Suspicions should be raised about the quality or need for SRP if very little or no anesthesia was required to complete the procedure (unless you know yourself to be quite pain tolerant). Time is also a factor in assessing the quality of the work completed. A deep cleaning is labor intensive and requires a substantial amount of time to complete. This is why more suspicions should be raised if a dentist suggests doing all four quadrants (the entire mouth) in one visit or if the procedure takes too little time to complete. A reasonable amount of time to do half the mouth would be 90-120 minutes. If the dentist or hygienist is able to complete half a mouth of SRP in less than 75 minutes, this is usually a sign that all or part of this procedure was never needed or that the procedure was done poorly. I recommend asking the office how long the procedure will take before committing to it – some judgments can be made based on the answer.

Keep in mind that when SRP is done correctly, there are multiple injections of anesthesia involved (four, five or more injections is not uncommon). Usually, half your face (either right or left) will be numb and most patients find the experience to be quite unsettling and somewhat exhausting. The process of removing calculus under the gums can be intense and many patients describe it as the hardest part of their dental treatment (when compared to crowns, fillings and even extractions). Some patients find it to be a much better experience if they are lightly sedated either with nitrous oxide (laughing gas) or with pills (valium, triazolam, etc.). SRP is also challenging for the patient because of the time involved and the significant amount of “scraping” required to remove all the calculus and smoothing of the root surfaces. Naturally, patients respond to treatment differently and some people find the experience to be no problem at all. But since most people find it intense, it would raise some concerns in my mind if nearly everyone in a dental practice was getting deep cleanings that they described as relaxing and easy. There will always be those patients that are highly tolerant of medical procedures with high pain thresholds, but they are not in the majority.

The latter description sounds rather awful to most people, which is why we don’t recommend SRP lightly to anyone. Nevertheless, if a patient genuinely needs it, there is simply no other way to circumvent the problem but to do SRP. This is why I discourage patients from automatically assuming a recommendation for SRP is just a money-making tactic or some sort-of gimmick. When indicated and properly performed, SRP is an important step towards improving total health as well as keeping teeth longer and healthier. It is worth doing under the right circumstances and this point cannot be overstated.

CONCLUSION:

It is a patient’s right to understand why a recommendation for a deep cleaning is being made. It is helpful to have the dentist point out the calculus and bone loss on the x-rays (which can be seen in the majority of cases). The dentist should also freely share the full mouth probing and explain where deeper pockets were found and how they relate to the general health of the gums. If the dentist or hygienist never recorded pocket depths at all, then this further raises suspicions of how the diagnosis was made. Some more advanced cases can be easily diagnosed with x-rays alone, but most cases require a full mouth probing as well. Independently of the dentist, if you see blood every time you brush, this adds support to the diagnosis of periodontitis. It is always appropriate to ask the dentist to explain why he or she recommended a deep cleaning as opposed to something simpler. If in doubt, I always recommend getting a second opinion.

Once a deep cleaning is done, maintenance is an important step to keeping things healthy; however, I do not believe that maintenance procedures need to be continued indefinitely for everyone. The topic of maintenance and the need for it will be covered separately.

Jun 212015
 

Short Answer: Silicone for a mouth guard and Gold for a night guard

Long Answer: This question comes up occasionally because there is more and more public awareness about the dangers of plastics. Most people know about Bisphenol A (BPA) which is a chemical used in the production of plastics. It can be found lining soda cans, plastic wrap, canned food and even in the thermal paper of sales receipts (which is readily absorbed through your skin when you handle them). It was banned from use in all children’s products in 2012 due to concerns about health effects. But companies soon started substituting BPA with a different compound called Bisphenol S (BPS). Many scientist believe BPS is even more potent and potentially more toxic than BPA. I really couldn’t make this up!

The marketing departments of these manufactures get to slap a big and proud “BPA-Free” label on their products but fail to mention what new chemicals they substituted in its place. Additionally, it also doesn’t mean your only concern should be BPA or BPS. There are other chemicals found in some plastics like Phthalates, Vinyl Chloride, Dioxins and Styrenes. Suffice it to say, I believe that no matter what a manufacturer claims, plastics are generally not to be trusted and they should be avoided when it is practical and reasonable. I have personally gone to great lengths to avoid contacting these chemicals, from getting a stainless steel blender, having the butcher put meat in my own glass container, not touching store sales receipts with my bare fingers and having absolutely no canned-anything in my house. That is just a short list of everything I have done 🙂 Am I a little crazy? Maybe. But I really believe plastic is not a good thing.

ATHLETIC MOUTH GUARD

So what is a patient to do if they need an athletic mouth guard?  99% of all these products are made of some plastic. Typically, athletic mouth-guards are soft and are made of a variety of plastics and usually some kind of copolyester. It is both impractical and not beneficial to make an athletic mouth guard from a rigid material, which is why it must be relatively thick and somewhat soft. In my own research, I have found that silicone is an exceptionally safe and effective alternative to traditional plastics. I use it in situations where I require a soft and pliable material. For example, I use a silicone spatula, baking sheet and reusable sealable bags, all made from 100% silicone. You can do your own research, but suffice it to say, I believe silicone is the only safe material out there that behaves like typical plastic. The good news is that you can have athletic mouth guards made from silicone, and that would be my preferred material for making one.

NIGHT GUARD

As for a night guard designed to protect from bruxism (tooth grinding), that is a whole different situation. I do not recommend anything soft for addressing bruxism, because a poorly adjusted soft night guard has the potential to cause jaw joint issues (TMD) and can also lead to an increase in grinding during the night. I will leave the issue of night guards for another post, but the bottom line is that a night guard should be rigid. Typically, dentists make hard night guards from acrylics, and usually (MMA) Methyl Methacrylate, Urethane Methacrylate, Stearyl Acrylate and others. Picture of a gold and plastic night guardThese materials do work very well and I make night guards using them for my patients today. That is because most people are not as health obsessed as I am and all these materials have been evaluated by the FDA and other health governing bodies like the American Chemistry Council. They have been found to be safe, so I cannot honestly say that I am sure a hard night guard made of plastic will harm you in any way. Also, since the majority of hard night guards are acrylic-based, you can rest assured they have no BPA or BPS in them. That doesn’t mean other harmful chemicals are not present, but at least you can know there is no BPA/BPS in any of them. With few exceptions, no modern dental material has BPA in it and all dental materials made in a lab have been evaluated by the Food and Drug Administration. http://www.ada.org/en/member-center/oral-health-topics/bisphenol-a

When in doubt, ask your dentist for the “MSDS” (Material Safety Data Sheet) for whatever product the lab is making your night guard from. Most will provide it and you can verify what is being used. There are some states where dental labs are not required to disclose the materials being used, so your situation may be different.

Despite any reassurances, if you are deeply concerned, then the best alternative I have found is to make a device out of gold (or gold alloy). You can also read here to find out why I think gold is safe. Unfortunately, it is not cheap to make a gold night guard. A typical well-adjusted hard night guard made of plastic would cost you about $500 at a dental office. An equivalent gold night guard could run in the $3,000-$4,000 range, and most dentists would look at you funny if you even asked about it. You would have to be pretty concerned to justify such an expense. On the other hand, a gold night guard could potentially last a lifetime, as opposed to a plastic one which requires replacement every 5 years or so. And you would rest assured (pun intended) that the product you have sitting in your mouth for 1/3 of your life has no potentially harmful chemicals. I personally think it’s worth it, but then again, I admit to being a little weird.Gold night guardA gold night guard in use

The bottom line is this: If you need an athletic mouth guard, I would recommend having one made of 100% silicone with no added coloring or scents, etc.. If you need a night guard, I would always recommend a well adjusted hard one. And if you could afford it, the safest material to make it from is clearly gold.

 

May 062015
 

Short Answer: 24-karat Gold, Grade-1 Titanium or Zirconia (in certain cases)

Long Answer: There are many materials crowns and fillings can be made from: Fillings, for example, can be made from a composite resin (basically hard plastic), amalgam (mercury metal filling), porcelain (there are many types) and cast metals (gold or non-precious alloys). But with so many to choose from, the “best” one depends a lot on your budget, tolerance for things not-white in your mouth, patience for longer or multiple appointments and priority placed on the “healthiest” materials. This post focuses on the latter, but I will briefly address the pros and cons of the other materials. Incidentally, crowns can be made from the same materials as fillings, but typically they are made of porcelain or a gold alloy fused to porcelain (also known as a “porcelain-fused-to-metal” crown). Here is a brief and quick summary of the different materials available:

Materials ComparisonThis post could literally go on forever in order to cover the full scope of the available materials. For practical purposes, I will say that the healthiest materials to put in your mouth continue to be Grade-1 titanium (the kind dental implants, artificial joints, etc are made from) and pure gold. This is based on many studies that show the level certain metals have on cell health (cytotoxic) and what kind of immune reaction they illicit. Gold and titanium are generally the gold standards (yes, pun intended) for bio-compatible materials.

As for gold crowns, it is quite rare to have one made out of pure 24k gold. This is because gold is soft and pliable and it would be hard to work with and would wear very quickly in the mouth in a pure form. So usually gold is mixed with other metals, most often they are palladium, silver, copper, zinc, iridium, platinum and more. Depending on the actual content, a dental metal is classified as being “high noble, titanium, noble or a base alloy”. See below:

Alloy comparison

The chart above shows metals in the order I would choose when having crowns in my own mouth (when purely considering bio-compatibility). Although high noble alloys are at least 40% gold, I generally recommend alloys that have more than 60% pure gold. Naturally, this is expensive to make when compared to other options. But the more gold in an alloy, the less there is of “other” metals. Titanium would be my next choice and I would forgo noble and non-precious alloys. Many people get what are known as “PFM” or “porcelain fused to metal” crowns which are basically thin gold crowns covered with a white porcelain material. Most porcelains are generally safe although they may contain aluminum oxide and even heavy metals (such as cobalt, barium or cadmium). The main disadvantage of a PFM is that the porcelain coating can break off the gold center piece over time. Also, the porcelain is abrasive and hard which causes teeth that oppose it to wear faster than normal. So, if a gold/metal crown was not an option, I would select a pure zirconia oxide material as the most bio-compatible of the porcelains. Zirconia is very strong and has been found to be highly bio-compatible in many studies and some dental implants are now being made of the material (a good sign that the body tolerates it well).

But sticking to the topic of metal crowns, when it comes to dental billing, some unscrupulous dentists will charge you and your insurance for a “high noble” crown but then have the laboratory make one using a lower grade and much cheaper metal. Some dentists even have a laboratory in China or other foreign country make their crowns, places where it is extremely difficult to verify what they are actually making the crowns from.  To make matters worse, some laboratories will actually tell an honest dentist they used a high noble metal, when in fact, they did not. All this happens for obvious reasons and it happens more than some people think. That’s because it is is extraordinarily hard to know for sure what it is you got without testing it and it’s extremely easy to fudge the truth. I wish I had some easy foolproof way to detect this type of fraud, but it is very difficult. Some people who are sensitive to base metals will develop gum irritations around the crown edges and this might be a sign of a problem. Also, color alone is not an indicator because even crowns with hardly any gold at all can be made to look gold in color.

Ultimately, you have to trust your dentist and make it very well known that the subject concerns you. Fully expect to get a high noble metal crown if that’s what you or your insurance is paying for. I would also recommend asking your dentist where the crowns are made, and at minimum, I would insist on a US-based laboratory. I personally charge a little extra if a patient requests a crown with gold content beyond 60% because my costs go up accordingly, but the conversation is always open and honest.

So to answer the original question, I don’t think any one thing to put in your mouth is perfect except for your original enamel. But if a crown is required, ideally it would be made from a high noble alloy with more than 60% gold. If a white crown was preferred, I would select a zirconia material.

May 042015
 

Short Answer: No, it’s not.

Long Answer: Dentists don’t bring up the topic of implants when discussing a missing tooth for many reasons. Many times, regrettably, it is because of financial considerations or simple ignorance.  One can assume the dentist has the best of intentions and simply thinks you cannot afford an implant or you cannot endure the procedure for some medical reason. These may be valid reasons, but they can be included in the conversation and in the final recommendations. But to omit the topic altogether is inappropriate. I don’t think there are any situations where at least the topic of implants shouldn’t come up when discussing a missing tooth. Some dentists are simply not comfortable with implants in general. They feel they are too complicated, time-consuming or they just don’t have a knack for them. That in itself is not a problem. I don’t like and am not necessary an expert at every possible procedure in dentistry; however, that doesn’t excuse the omission of such a treatment option and a referral to a dentist who can complete that part of the treatment if the patient ultimately chooses to have an implant.

Some dentists don’t discuss implants because of their own financial considerations. It is usually advantageous for a dentist to do one of the other options before recommending an implant for several reasons: When a dentist recommends an implant, he typically first makes a referral to a specialist (like a periodontist or oral surgeon) to surgically place the implant. This may account for half of the total fee which is now being charged by someone else, that is, if the patient ever goes. It has been cited that over 35% of patients being referred to a surgeon for an implant never actually go [The Journal of Dentistry, 38, 173-181. Levin, R. (2004) Implant dentistry and patient financing.]. So there is already a good chance that more than a third of patients will never follow through and the dentist will never profit from any procedure. For those that do make an appointment and have an implant placed, there is usually a healing period of 3-6 months before the newly placed implant is suitable to get a new crown on it. This is yet another 3-6 months that the dentist has earned no money. Many things can happen in that time: the patient could move, run into financial trouble, have changing life circumstances, new medical issues, etcetera. Should any of these happen during the 3-6 months of waiting, once again the dentist will not see a penny of profit. Assuming everything falls into place and the patient has an implant placed and waits the 3-6 months, then the dentist’s profit is still not all it could have been. Although it depends on where the dentist is located, a typical fee for a crown and abutment (the part between the implant and the final tooth/crown) may be $2,200. From that, the dentist must pay a special laboratory to make everything, not to mention other parts, pieces and materials which could easily add up to about $700. All in all, the dentist may spend about 1 hour 30 minutes to do everything needed from start to finish. With a gross profit of about $1,500, this translates to $1,000/hour. Although it sounds like a lot, it is important to re-emphasize that this is gross profit, not what the dentist takes home. But in any case, there is more to be made with alternative procedures as is shown next.

Instead of an implant, the dentist could do a bridge (two crowns connecting a fake tooth between them which fills the gap). When a dentist does a bridge, the finances skew more in the dentist’s favor. A “3-unit” bridge for one missing tooth may cost the patient about $3,000. Unlike with an implant, the patient does not get referred anywhere else and the work can start immediately. Also, laboratory fees for a bridge are usually less than for an implant because the work does not need to be as precise and there are fewer specialty parts involved. But for the sake of comparison, let’s say the laboratory charged the same $700. In this case, the dentist made $2,300 and the money was collected immediately. In total, the dentist spent approximately 2 hours doing this procedure from start to finish. This translates to $1,150/hour (about 15% more than when doing an implant). So from purely a financial standpoint, what makes more sense for the dentist: Recommending a procedure that he may (if all the stars align) profit $1,500 from in 3-6 months or one where he will profit $2,300 from immediately? Bottom line: some dentists may see no financial reason to offer or even discuss implants in their practice. If you are missing a tooth and there is no mention of an implant, consider getting a second opinion.